Cancer breakthrough pain characteristics and responses to treatment at a VA medical center

Definition and Assessment of Paediatric Breakthrough Pain: A Qualitative Interview Study

Infants, children and young people with life-limiting or life-threatening conditions often experience acute, transient pain episodes known as breakthrough pain. There is currently no established way to assess breakthrough pain in paediatric palliative care. Anecdotal evidence suggests that it is frequently underdiagnosed and undertreated, resulting in reduced quality of life. The development of a standardised paediatric breakthrough pain assessment, based on healthcare professionals' insights, could improve patient outcomes. This study aimed to explore how healthcare professionals define and assess breakthrough pain in paediatric palliative care and their attitudes towards a validated paediatric breakthrough pain assessment. This was a descriptive qualitative interview study. Semi-structured interviews were conducted with 29 healthcare professionals working in paediatric palliative care across the UK. An inductive thematic analysis was conducted on the data. Five themes were generated: 'the elusive nature of breakthrough pain', 'breakthrough pain assessment', 'positive attitudes towards', 'reservations towards' and 'features to include in' a paediatric breakthrough pain assessment. The definition and assessment of breakthrough pain is inconsistent in paediatric palliative care. There is a clear need for a validated assessment questionnaire to improve assessment, diagnosis and management of breakthrough pain followed by increased healthcare professional education on the concept.

What to Do and What Not to Do in the Management of Cancer Pain: A Physician Survey and Expert Recommendations

BACKGROUND

Despite the prevalence of pain among patients with cancer and the availability of pertinent guidelines, the clinical management of oncological pain is decisively insufficient. To address this issue, we evaluated current trends in clinical practice and subsequently generated a list of ten corrective actions-five things to do and five things not to do-for the diagnosis, management, and monitoring of cancer pain.

METHODS

The survey included 18 questions about clinical practice surrounding background pain and breakthrough cancer pain (BTcP). Survey questions were developed by a scientific board of 10 physician experts and communicated via email to an expanded panel of physicians in Italy. Responses were tabulated descriptively for analysis.

RESULTS

Of 51 invited physicians, 32 (63%) provided complete survey responses. The responses revealed several incongruencies with current guideline recommendations: physicians did not always diagnose or monitor pain using diagnostically validated or disease-specific instruments; frequently based clinical decision-making on time availability or convenience; and pharmacological therapy was often inappropriate (eg, prescribing NSAIDs or corticosteroids for BTcP). The list of corrective actions generated by the scientific board favored a guideline-oriented approach that systematically characterizes oncological pain and implements treatment based on pain characteristics (eg, fast-acting transmucosal opioids for BTcP) and evidence-based recommendations.

CONCLUSION

Oncologists require better education and training about the diagnosis, treatment, and monitoring of oncological pain. Physicians should be aware of current guideline recommendations as well as available pharmacological tools for BTcP.

Pain Perception and Management: Where do We Stand?

BACKGROUND

Pain is often flammable, sharp and sometimes described as an electrical shock. It can be categorized in three different ways as nociceptive, neuropathic and inflammatory. Nociceptive pain always originates in specific situations such as in trauma. Neuropathic pain results in nerve damage. In inflammatory pain, inflammatory mediators are involved in the sensitization of nociceptors. It is important to control the pain as it affects the individual physically, mentally, and socially.

OBJECTIVE

Recognizing pain physiopathology and pain pathways, defining the relationship between receptor and transmitter is critical in developing new treatment strategies. In this review, current information on the definitions, classifications, and physiological and chemical mechanisms involved in pain are reviewed.

METHODS

Various search engines were used to gather related articles/information. Only peer-reviewed journals were considered. Additional, books/chapters of standard publishers were also included in the article.

RESULTS

With a better understanding of the physiological and chemical mechanisms that play a role in pain, significant improvements have been made in pain treatment. Various oral or intravenous drugs, local injection treatments, physical and occupational therapy, electrical stimulation, alternative medicine applications, psychological support, and surgical applications are routinely performed in the treatment, dependent upon the type, severity and cause of the pain.

CONCLUSION

Improved understanding of pain physiopathology will serve as the basis for future improvements in the delivery of efficacious and reliable treatments, and is likely to rely on novel technological innovations.

Cancer Pain Assessment and Classification

More than half of patients affected by cancer experience pain of moderate-to-severe intensity, often in multiple sites, and of different etiologies and underlying mechanisms. The heterogeneity of pain mechanisms is expressed with the fluctuating nature of cancer pain intensity and clinical characteristics. Traditional ways of classifying pain in the cancer population include distinguishing pain etiology, clinical characteristics related to pain and the patient, pathophysiology, and the use of already validated classification systems. Concepts like breakthrough, nociceptive, neuropathic, and mixed pain are very important in the assessment of pain in this population of patients. When dealing with patients affected by cancer pain it is also very important to be familiar to the characteristics of specific pain syndromes that are usually encountered. In this article we review methods presently applied for classifying cancer pain highlighting the importance of an accurate clinical evaluation in providing adequate analgesia to patients.

Breakthrough cancer pain: The importance of the right treatment at the right time

BACKGROUND

Confusion remains over the definition of breakthrough cancer pain (BTcP) potentially leading to delayed diagnosis and treatment.

METHODS

An on-line survey was conducted in four EU countries among relevant healthcare professionals and cancer patients diagnosed with BTcP. The roles of healthcare professionals (HCPs) were examined and their knowledge and use of available medications recorded. Patients were questioned on how BTcP affected their lives and on the medications they had received/were receiving.

RESULTS

There was a 'time lag' of 58 and 13 weeks in Germany and Spain respectively between the initial diagnosis of BTcP and its treatment. Four in ten oncologists across the four countries considered themselves not fully confident in their choice of the appropriate therapy. A quarter of patients in Germany, Italy and Spain and four in ten in France were treated only with increased dosages of the therapy already prescribed for their background pain - often morphine. Almost another quarter received morphine in addition to their treatment for background pain. Oncologists indicated a need for faster-acting treatments revealing a potential lack of awareness of rapid onset oral opioids and patients expressed a desire for more effective pain relief and better psychological support.

CONCLUSIONS

There is a need for a universal definition of BTcP to facilitate earlier and more accurate diagnosis. It is essential that BTcP is treated immediately on diagnosis with therapies that more closely mirror its temporal characteristics to ensure that patients' desire for more effective pain relief is fulfilled.

SIGNIFICANCE

Many cancer patients suffered episodes of BTcP needlessly over many months due to missed diagnosis. Even after diagnosis, many physicians were not fully confident in their choice of 'rescue' therapy which perhaps is not surprising given the very low level of awareness of treatment guidelines, both national and international.

Cancer pain management: recommendations from a Latin-American experts panel

Generating a consensus in the Latin-American region on cancer pain management is a current need. Thus a panel of Latin-American experts met in Madrid in March 2017 in order to review the published literature, discuss the best approach for cancer pain classification and evaluation and also make recommendations of pharmacological and nonpharmacological therapies for cancer pain management improvement in Latin-American countries. The result of that meeting is presented in this document. The experts participating were from Costa Rica, Mexico, Chile, Colombia, Peru, Brazil and Ecuador, and the project coordinator was from Spain.

Characteristics and Treatment of Breakthrought Pain (BTcP) in Palliative Care

INTRODUCTION

This research was to follow characteristics of breakthrough pain caused by cancer (BTcP) and other most common sympthoms (ESAS) at patients in advanced stage of cancer disease in palliative care.

PATIENTS AND METHODS

Prospective study included 433 patients which were treated in Palliative Care Centre in UKC Tuzla, Bosnia and Herzegovina. Group 1 was consisted of 353 patients whose basal cancer pain of intensity 4-7 NRS was treated weak opiates (basal analgetic- fixed combination of tramadol/paracetamol (37.5 mg/325 mg) in initial dose 3x1tbl for pain intensity 4, to 4x2tbl (for pain intensity 7). In Group 2 (80 patients) basal pain of intensity 8-10 was treated strong opiates as basal analgetic (oral morphine and transdermal fentanil). If the previous day were 2 or more breakthrough pain that required ''rescue dose'' of analgetics (tramadol 50-100 mg orally in group 1 ie. Oral morphine 8-12 mg in the group 2), the dose of basal analgetic was increased.

RESULTS

The total number of reported breakthrough pain in all 433 patients for 10 days of treatment was 3 369 (0.78 BTcP /per patient/day), where at Group 1 patients showed significantly lower BTcP (0.56 BTcP/patient/day). The average intensity of BTcP was 5.91 where in the Group1 was 4.51 while in the Group 2 8.04. 582 (17.28%) was rated grade 7, of which 539 were successfully coupled by strong and 43 (7.39%) successfully coupled by weak opiates. From 556 BTcP who were rated with 8, 540 of them were coupled strong and only 16 successfully coupled by weak opiates. 1967 (58.39 %) of breakthrough pain has occured in the evening hours (18-06 h), while 1402 (41.62%) BTCP occured during day hours (06-18h). Most (1290 or 38.29%) of breakthrough pain lasted less than 10 minutes, 882 (26.18%) between 16 and 20 minutes, 752 (22.32%) between 11 and 15 minutes, 407 (12.8%) between 21 and 30 minutes and 38 (1.13%) lasted longer than 20 minutes.

CONCLUSION

Duriong our study, we noted a relatively large number of breakthrough pain with lower intensity (3-6) in patients treated with weak opiates, which are also adversely affected patients satisfaction with pain treatment and required additional doses of analgetics. In the small percentage is possible the breakthrough pain of stronger intensity (7-8) treat by maximum doses of weak opiates.

What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion

Clinical management of breakthrough cancer pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five ‘things to do’ and five ‘things not to do’ in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.

Satisfaction with and Perception of Pain Management among Palliative Patients with Breakthrough Pain: A Qualitative Study

Breakthrough pain is a significant contributor to much suffering by patients. The experience of intense pain may interfere with, and affect, daily life functioning and has major consequences on patients' well-being if it is not well managed. The area of breakthrough pain has not been fully understood. This study thus aimed to explore the experiences of breakthrough pain among palliative patients. A qualitative study based on a series of open-ended interviews among 21 palliative patients suffering from pain at an urban tertiary hospital in Malaysia was conducted. Five themes were generated: (i) pain viewed as an unbearable experience causing misery in the lives of patients, (ii) deterioration of body function and no hope of recovery, (iii) receiving of inadequate pain management for pain, (iv) insensitivity of healthcare providers toward patients' pain experience, and (v) pain coping experiences of patients. The findings revealed that nonpharmacologic approaches such as psychosocial support should be introduced to the patients. Proper guidance and information should be given to healthcare providers to improve the quality of patient care. Healthcare providers should adopt a sensitive approach in caring for patients' needs. The aim is to meet the needs of the patients who want to be pain free or to attain adequate relief of their pain for breakthrough pain.

Characteristics of breakthrough cancer pain and its influence on quality of life in an international cohort of patients with cancer

OBJECTIVES

Breakthrough cancer pain (BTP) represents a treatment challenge. Objectives were to examine the prevalence and characteristics of BTP in an international sample of patients with cancer, and to investigate the relationship between BTP and quality of life (QoL).

METHODS

This was an observational cross-sectional multicentre study. Participating patients completed self-report questionnaires on a touch-screen laptop computer, including the Brief Pain Inventory, Alberta Breakthrough Pain Assessment Tool (ABPAT) and European Organisation for Research and Treatment of Cancer 30-item Core Quality of Life Questionnaire (EORTC QLQ-C30). The study was performed in 17 centres in 8 countries and involved 4 languages (Norwegian, Italian, German and English).

RESULTS

Records from a convenience sample of 978 patients with advanced cancer were analysed; mean age was 62.2 years, 48.3% were women and 84.4% had metastatic disease. A total of 296 patients (30%) had no pain, defined as worst pain in the past 24 hours <1 on a 0-10 scale. Of the 682 patients with a pain score ≥1, 393 (58%) reported no BTP on the screening item, while 289 (30%) confirmed flare ups of BTP. Patients with BTP reported significantly higher pain intensity scores (<0.001) than patients without BTP; 57.1% of patients rated BTP at its worst as being severe: ≥7 on a 0-10 scale. Time from onset to peak intensity was <10 min for 42.9%, and average time to pain relief was 27.1 min. BTP was commonly triggered by medication wearing off (28%). Patients with BTP had significantly worse mean outcomes on 10 of 15 functional and symptom scales of the EORTC QLQ-C30 (<0.001). Severe pain intensity in the last week was a powerful predictor of BTP (OR 4.1) and poor QoL (OR 1.9).

CONCLUSIONS

BTP is highly prevalent with prolonged episodes despite analgaesics, and has a pervasive impact on QoL. Patients reporting high pain intensity should be carefully evaluated for BTP and efficacy of analgaesic treatment, to provide optimal pain management and improve QoL.

TRIAL REGISTRATION NUMBER

NCT00972634; Results.

Fentanyl sublingual spray for breakthrough cancer pain in patients receiving transdermal fentanyl

AIM

To investigate the relationship between effective fentanyl sublingual spray (FSS) doses for breakthrough cancer pain (BTCP) and around-the-clock (ATC) transdermal fentanyl patch (TFP).

METHODS

Adults tolerating ATC opioids received open-label FSS for 26 days, followed by a 26-day double-blind phase for patients achieving an effective dose (100-1600 µg).

RESULTS

Out of 50 patients on ATC TFP at baseline, 32 (64%) achieved an effective dose. FSS effective dose moderately correlated with mean TFP dose (r = 0.4; p = 0.03). Patient satisfaction increased during the study. Common adverse event included nausea (9%) and peripheral edema (9%).

CONCLUSION

FSS can be safely titrated to an effective dose for BTCP in patients receiving ATC TFP as chronic cancer pain medication. ClinicalTrials.gov identifier: NCT00538850.

Correlations between plasma endothelin-1 levels and breakthrough pain in patients with cancer

Endothelin-1 (ET-1) may be involved in driving pain in patients with advanced cancer. However, a few studies focus on the role of ET-1 in breakthrough pain (BP). The aim of this pivotal study was to explore the correlation between the plasma (ET-1) level and BP intensity. A total of 40 patients were enrolled in the study, and they were divided into two groups: BP group and non-BP group. Moreover, 20 healthy adults were used as the normal control group. Pain intensity was measured using visual analog scale (VAS) scores of 1–10. Plasma ET-1 levels were detected by an ET radioimmunoassay kit. Subsequently, the correlation of ET-1 level with the VAS score and cancer types was analyzed by Pearson’s correlation coefficient. The plasma ET-1 level in the BP group (35.31±8.02 pg/mL) was higher than that in the non-BP group (29.51±6.78 pg/mL) and the normal control group (24.77±10.10 pg/mL, P<0.05). In addition, the VAS score in the BP group (7.45±0.82) was higher than that in the non-BP group (2.80±1.23, P<0.05). The plasma ET-1 level was positively correlated with the VAS score of the BP group (Pearson’s r=0.42). There was no significant correlation between the plasma ET-1 level and VAS score of the non-BP group (Pearson’s r=−0.22) or/and cancer types (P>0.05). The elevated plasma ET-1 levels were positively related to BP, and targeting ET-1 may provide a novel pain-reducing therapeutic treatment in BP.

Accuracy of a Diagnostic Algorithm to Diagnose Breakthrough Cancer Pain as Compared With Clinical Assessment

CONTEXT

Breakthrough cancer pain (BTCP) is a heterogeneous condition, and there are no internationally agreed standardized criteria to diagnose it. There are published algorithms to assist with diagnosis, but these differ in content. There are no comparative data to support use.

OBJECTIVES

To compare the diagnostic ability of a simple algorithm against a comprehensive clinical assessment to diagnose BTCP and to assess if verbal rating descriptors can adequately discriminate controlled background pain.

METHODS

Patients with cancer pain completed a three-step algorithm with a researcher to determine if they had controlled background pain and BTCP. This was followed by a detailed pain consultation with a clinical specialist who was blinded to the algorithm results and determined an independent pain diagnosis. The sensitivity, specificity, and positive and negative predictive values were calculated for the condition of BTCP. Further analysis determined which verbal pain severity descriptors corresponded with the condition of controlled background pain.

RESULTS

The algorithm had a sensitivity of 0.54 and a specificity of 0.76 in the identification of BTCP. The positive predictive value was 0.7, and the negative predictive value was 0.62. The sensitivity of a background pain severity rating of mild or less to accurately categorize controlled background pain was 0.69 compared with 0.97 for severity of moderate or less; however, this was balanced by a higher specificity rating for mild or less, 0.78 compared with 0.2.

CONCLUSION

The diagnostic breakthrough pain algorithm had a good positive predictive value but limited sensitivity using a cutoff score of "mild" to define controlled background pain. When the cutoff level was changed to moderate, the sensitivity increased, but specificity reduced. A comprehensive clinical assessment remains the preferred method to diagnose BTCP.

WITHDRAWN: Opioids for the management of breakthrough pain in cancer patients

At August 2015, this review has been withdrawn. It is correct at the date of publication, and previous versions can be accessed in the ‘Other versions’ tab on the Cochrane Library. The Cochrane Editorial Unit (CEU) agreed with the authors of the feedback that the review was misleading, and because the original author team was unavailable to update the review, the CEU advised that it should be withdrawn. See below for full details. PaPaS is seeking a new author team to develop a new review which will serve to update the original.

Feedback 1, received 15 February 2015

Dr Vicente Ruiz Garcia
 vicenteruizgarcia@gmail.com

With colleagues Xavier Bonfill Cosp, Eduardo Lopez Briz, Rafa Carbonell, Jose Luis Gonzalvez Perales, Sylvia Bort Martí, and Marta Roque Figuls.

Comment: Dear editor:

We have read the update of Zeppetella and Davies about management of breakthrough pain in cancer patients (1). We think that this review is very important to help clinicians and patients to decide whether the new treatments for the breakthrough pain in cancer could be a useful alternative to morphine.

In this update, some comments that we made to the previous review (the letter was not published) (2) were considered by the authors; in particular, not pooling the results obtained for oral transmucosal fentanyl citrate (OTFC) versus placebo, with those of OTFC versus morphine, and those of two trials that were titration of doses of fentanyl. However, we do not agree with the authors’ results when they state: “When compared with placebo or oral morphine, participants gave lower pain intensity and higher pain relief scores for transmucosal fentanyl formulations at all time points”. First, the outcomes at 15 min (the most important to obtain a quick relief of pain), Pain intensity Difference (Comparison 2. Transmucosal opioid versus oral morphine) and Comparison 4. OTFC versus intravenous morphine), failed to show statistically significant differences with oral morphine (mean difference 0.37 CI 95% 0.00‐0.73) and with morphine iv (mean difference 0.80 CI 95% 0.00‐1,60). In any case the results had no clinical relevance. Moreover the authors state “at all time points”, whereas they do not provide any data for longer times (i.e. 30, 45, 60 min). In addition, authors state “transmucosal fentanyl citrate are safe (..) (compared with both placebo and morphine) in relieving breakthrough pain”. Surprisingly no analysis of adverse events have been done that were only described in each study. Seven out 15 were crossover trials and it was impossible to draw conclusions about it.

As reviewers we know that multiple comparisons could be made, but the most clinical interesting comparison is the gold standard, morphine.

The review only shows in SOF, comparisons of fentanyl with placebo and concludes, that it is effective. Surprisingly, there is no mention of morphine comparison, which we consider a key point, because no patient will take placebo if he has a breakthrough pain, but morphine for obvious reasons.

In our opinion, traversing the authors’ conclusions, this review did not show that the use of oral and nasal transmucosal fentanyl is an effective alternative to morphine for patients with breakthrough cancer pain.

Reply

The authors of the review were contacted but chose not to provide a response to the feedback.

Contributors

Kate Seers, PaPaS Feedback Editor, and Anna Hobson, PaPaS Managing Editor.

Additional feedback 2, received May 2015

On 15 February 2015, Dr Vicente Ruiz Garcia (University Hospital La Fe, Spain), and his colleagues Xavier Bonfill Cosp, Eduardo Lopez Briz, Rafa Carbonell, Jose Luis Gonzalvez Perales, Sylvia Bort Martí, and Marta Roque Figuls submitted feedback via the Cochrane Library. The main complaint is available above.

On 23 February, 16 March and 15 April, Kate Seers (Feedback Editor, PaPaS) contacted the authors and invited them to respond. On 21 March, John Zeppetella (lead author) declined to provide a formal response. No response was received from Andrew Davies (second author).

On 31 March, PaPaS sought advice from the Cochrane Editorial Unit (CEU) on how to manage the issue; advised to publish without a response, depending on nature of feedback.

On 11 May 2015, review re‐published with feedback incorporated.

On 20 May 2015, Marta Roqué Figuls (Statistician, Iberoamerican Cochrane Centre) wrote to the CEU repeating the initial claim. They did not agree with the approach decided upon by the Co‐Ed, which was supported by the EiC. They stated “The CCIb assessment is that the review presents methodological shortcomings, and the conclusions are skewed in favor of fentanyl. Consequently, we support Vicente and colleagues’ petition to re‐assess the publication status of the review.”

Reply

On 9 June, Christopher Eccleston (Co‐ordinating Editor, PaPaS) advised that the review remain unchanged until it was ready for updating in September 2015.

On 25 June 2015 David Tovey (Editor in Chief, Cochrane) responded to say “We have now had a chance to appraise this review and also obtain a report from our screening team… In summary we agree with almost all of the criticisms made of the review, and are concerned that the flaws may mean that the findings are misleading as currently presented. We note that the authors have declined to respond to the useful comments provided by Vicente. Having considered this and discussed it internally, we agree with our colleagues at the IbCC that the review should be withdrawn temporarily until the errors have been fixed and the review updated. We would like to re‐screen the review before any update or amendment is published.”

On 2 July and 23 July, Anna Hobson (Managing Editor, PaPaS) again invited the authors to respond to the initial feedback and subsequent reviews by 23 July. No response was forthcoming.

At August 2015, the review was withdrawn.

Contributors

Kate Seers (Feedback Editor, PaPaS), Cochrane Editorial Unit (CEU), Christopher Eccleston (Co‐ordinating Editor, PaPaS), David Tovey (Editor in Chief, Cochrane), Anna Hobson (Managing Editor, PaPaS).

The editorial group responsible for this previously published document have withdrawn it from publication.

Breakthrough pain in elderly patients with cancer: treatment options

The prevalence of pain is high in the elderly and increases with the occurrence of cancer. Pain treatment is challenging because of age-related factors such as co-morbidities, and over half of the patients with cancer pain experience transient exacerbation of pain that is known as breakthrough pain (BTP). As with background pain, BTP should be properly assessed before being treated. The first step to be taken is optimizing around-the-clock analgesia with expert titration of the painkiller. Rescue medication should then be provided as per the requested need, while at the same time preventing identified potential precipitating factors. In the elderly, starting treatment with a lower dose of analgesics may be justified because of age-related physiological changes such as decreased hepatic and renal function. Whenever possible, oral medication should be provided prior to a painful maneuver. In the case of unpredictable BTP, immediate rescue medication is mandatory and the subcutaneous route is preferred unless patient-controlled analgesia via continuous drug infusion is available. Recently, transmucosal preparations have appeared in the medical armamentarium but it is not yet known whether they represent a truly efficient alternative, although their rapid onset of activity is already well recognized. Adjuvant analgesics, topical analgesics, anesthetic techniques and interventional techniques are all valid methods to help in the difficult management of pain and BTP in elderly patients with cancer. However, none has reached a satisfying scientific level of evidence as to nowadays make the development of undisputed best practice guidelines possible. Further research is therefore on the agenda.

Improved patient functioning after treatment of breakthrough cancer pain: an open-label study of fentanyl buccal tablet in patients with cancer pain

PURPOSE

This open-label study evaluated the effects of fentanyl buccal tablet (FBT) on functioning and mood in cancer patients with breakthrough cancer pain (BTcP).

METHODS

Opioid-tolerant patients in seven European countries with up to four BTcP episodes/day received FBT doses (100-800 μg) identified during open-label titration to treat up to eight BTcP episodes during an open-label treatment period. In countries where FBT was not commercially available, patients could enter an open-label continuation phase. Functionality and satisfaction assessments included change from baseline to the end of the treatment period in the modified Brief Pain Inventory (BPI-7S) seven-item interference subscale, patient's global assessment of satisfaction and ease of use, and Patient's Global Impression of Change (PGIC). Safety was also assessed.

RESULTS

Of 330 randomized patients, 218 completed the treatment period and 88 entered the continuation phase. Median background pain intensity was 4.0 (mild) throughout the study. After the treatment period, mean (SD) global modified BPI-7S score improved from 39.7 (15.9) at baseline to 31.6 (16.8) for a mean change of -8.6 (95% confidence interval CI -10.5, -6.7; P < 0.0001), and 74.5% of patients reported improvement in overall status (PGIC) compared with 25.5% who reported no change or worsening (P < 0.001). Treatment-related adverse events (≥2 patients) during the continuation phase were application site erythema (6.9%), application site swelling (4.6%), and vertigo (4.6%).

CONCLUSIONS

FBT may improve patient functioning, mood, and overall satisfaction in the management of BTcP. Long-term data did not indicate new safety concerns with FBT doses up to 800 μg.

Breakthrough pain management using fentanyl buccal tablet (FBT) in combination with around-the-clock (ATC) opioids based on the efficacy and safety of FBT, and its relationship with ATC opioids: results from an open-label, multi-center study in Japanese cancer patients with detailed evaluation

Objective

Rapid analgesic onset opioids, particularly fentanyl buccal tablet, is preferable for managing breakthrough pain. The efficacy and safety of fentanyl buccal tablet and its association with around-the-clock opioids needs to be explored with an option of dose adjustments, more closely reflecting administration in clinical practice. The aim of the study was to assess the safety and efficacy of fentanyl buccal tablet in breakthrough pain management in combination with around-the-clock opioids with the dose adjustment option, and explore the dose adjustment's influence on breakthrough pain management using detailed evaluation.

Methods

The 12-week open-label, multi-center study was conducted throughout Japan. Cancer patients aged 20 years or older, experiencing persistent pain controlled with around-the-clock opioids and breakthrough pain with supplemental medications were enrolled. Fentanyl buccal tablet and around-the-clock opioid doses could be adjusted under protocol-specified conditions. Efficacy variables were assessed at each fentanyl buccal tablet administration. Safety was assessed mainly by adverse events.

Results

All efficacy variables showed sustained analgesic effect. Nearly half the patients stayed on the same dose; most fentanyl buccal tablet administrations did not require additional supplemental medications. Dose increase of fentanyl buccal tablet and around-the-clock opioids seemed to improve breakthrough pain intensity and frequency, respectively. Fentanyl buccal tablet and around-the-clock opioid doses were not strongly associated. Treatment-related adverse events were all common with opioid treatment and did not increase over time.

Conclusions

Fentanyl buccal tablet can stably and safely manage breakthrough pain in cancer patients with independent dose adjustment based on detailed evaluation of each patient's condition. Breakthrough pain management using fentanyl buccal tablet with around-the-clock opioids at optimal doses may be an important factor in palliative care for cancer patients with breakthrough pain.

Development and validation of the breakthrough pain assessment tool (BAT) in cancer patients

CONTEXT

The successful management of breakthrough pain depends on a combination of adequate assessment, appropriate (individualized) treatment, and adequate re-assessment. Currently, there is no fully validated clinical assessment tool for breakthrough pain in cancer patients.

OBJECTIVES

The aim of this project was to develop and validate a breakthrough pain assessment tool (the BAT) for use in the clinical setting.

METHODS

The content of the BAT was determined by reviewing the medical literature, conducting a Delphi process with experts in breakthrough pain and/or pain assessment and conducting semi-structured interviews with cancer patients with breakthrough pain. The tool was then subjected to a series of standard psychometric tests to assess its factor structure, validity (i.e., content validity, construct validity), reliability (i.e., internal consistency, test-retest reliability), and responsiveness to change.

RESULTS

The BAT comprised two pages with 14 questions. Factor analysis confirmed the presence of two underlying factors. Psychometric testing confirmed that the tool is valid, reliable, and responsive to change.

CONCLUSION

This study provides initial evidence for the validity and reliability of the breakthrough pain assessment tool which may be used to facilitate the management of patients with breakthrough cancer pain in the clinical setting.

Breakthrough cancer pain (BTcP): a synthesis of taxonomy, pathogenesis, therapy, and good clinical practice in adult patients in Italy

Pain presents in 80% of patients with advanced cancer, and 30% have periods of increased pain due to fluctuating intensity, known as breakthrough cancer pain (BTcP). BTcP is high-intensity, short-duration pain occurring in several episodes per day and is non-responsive to treatment. The clinical approach to BTcP is variable. A review of the literature was performed to provide clinicians and practitioners with a rational synthesis of the ongoing scientific debate on BTcP and to provide a basis for optimal clinical approach to BTcP in adult Italian patients. Data show that circadian exacerbations of pain should be carefully monitored, differentiating, if possible, between fluctuations of background pain (BP), end-of-dose effect, and BTcP. BTcP should be monitored in all care contexts in clinical practice and each care facility must have all the medications and products approved for use in BTcP at their disposal. Data show that knowledge about medications for BTcP is lacking: medications for BTcP treatment are not interchangeable, although containing the same active substance; each physician must know the specific characteristics of each medication, its pharmacological properties, limitations in clinical practice, specifics relating to titration and repeatability of administration, and technical specifics relating to the accessibility and delivery. Importantly, before choosing a rapid-onset opioid (ROO), it is essential to deeply understand the status of patient and the characteristics of their family unit/caregivers, taking into account the patient’s progressive loss of autonomy and/or cognitive-relational functionality. When BTcP therapy is initiated or changed, special attention must be paid to training the patient and family members/caregivers, providing clear instructions regarding the timing of drug administration. The patient must already be treated effectively with opioids before introducing ROOs for control of BTcP.

A randomized, double-blind, placebo-controlled study of fentanyl buccal tablets for breakthrough pain: efficacy and safety in Japanese cancer patients

CONTEXT

Rapid-onset opioids for treating breakthrough pain (BTP) in patients with cancer are needed in the Japanese care setting.

OBJECTIVES

To examine the efficacy and safety of fentanyl buccal tablets (FBTs) for treating BTP in Japanese cancer patients.

METHODS

This was a randomized, double-blinded, placebo-controlled study. In subjects receiving around-the-clock (ATC) opioids at doses of 30 mg or more to less than 60 mg or 60-1000 mg of oral morphine equivalents (low and high ATC groups), dose titration was started from 50 to 100 μg FBT, respectively. Subjects whose effective dose was identified were randomly allocated to a prearranged administration order of nine tablets (six FBTs and three placebos), one tablet each for nine episodes of BTP (double blinded). Efficacy and safety of FBT were assessed for patients overall, and also for the low and high ATC groups.

RESULTS

A significant difference was observed between FBT and placebo for the primary endpoint of pain intensity difference at 30 minutes. The analgesic onset of FBT was observed from 15 minutes in several secondary variables (e.g., pain relief). Adverse events were somnolence and other events associated with opioids were mostly mild or moderate. Of the low and high ATC group subjects, an effective FBT dose was identified in 72.2% and 73.1%, respectively.

CONCLUSION

The safety of FBT and its analgesic effect on BTP were confirmed in Japanese cancer patients receiving opioids. Our findings suggest that analgesic onset may occur from 15 minutes after FBT, and that FBT can be administered to patients with low doses of ATC opioids.

The role of analgesic adjustment strategies in achieving analgesic efficacy in opioid-tolerant hospice patients in China

Diverse strategies of analgesic adjustment are often, respectively, used to sustain analgesic efficiency for opioid-tolerant patients with different refractory factors of pain. In order to select effective analgesic adjustment strategy for hospice patient without knowing explicit causes of diminishing analgesic efficiency, a retrospective data of 743 patients among 3760 hospice patients were analyzed. The efficacy and adverse effects were not significantly different among analgesic adjustment strategies at each adjustment. Opioid duration was not associated with clinical characteristics. For opioid-tolerant hospice patients, the analgesic adjustment strategy can be selected for individual patient. After repeated analgesic adjustments, opioid tapering may also occur.

A randomized, placebo-controlled study of a new sublingual formulation of fentanyl citrate (fentanyl ethypharm) for breakthrough pain in opioid-treated patients with cancer

BACKGROUND

Oromucosal fentanyl is currently used for the treatment of breakthrough pain (BTP) in opioid-treated cancer patients. Ethypharm developed a sublingual formulation of fentanyl suprabioavailable to oral transmucosal fentanyl citrate with a higher early systemic exposure and a shorter Tmax.

OBJECTIVES

This study evaluated the efficacy and safety profile of fentanyl Ethypharm (FE) in relieving BTP in opioid-treated cancer patients.

METHODS

Opioid-treated adult cancer patients, experiencing 1 to 4 episodes of BTP per day, were included in the study. After an open-label titration period to identify an optimal dose that would provide adequate pain relief for 2 consecutive episodes of BTP with an acceptable level of adverse events, patients were randomly assigned to a double-blind, placebo-controlled, crossover period with 1 of 13 prespecified sequences of 9 tablets (6 tablets of FE of the dose identified during the open-label titration and 3 placebo). Pain intensity and pain relief were recorded at 3, 6, 10, 15, 30, and 60 minutes after study drug administration. Adverse events were recorded. The primary end point was the sum of pain intensity differences (SPID) at 30 minutes.

RESULTS

The distribution of optimal dosages of FE was as follows: 133 µg, 35.9%; 267 µg, 30.8%; 400 µg, 14.1%; 533 µg, 12.8%; and 800 μg, 6.4%. In the modified intention-to-treat population (n = 73), FE significantly improved mean (SE) SPID compared with placebo at 30 minutes (75.0 [49.8] vs 52.5 [52.8]; P < 0.0001). FE significantly improved SPID, pain intensity difference, and pain relief compared with placebo from 6 to 60 minutes' postadministration. Patients with BTP who received placebo required the use of rescue medication more often than those treated with FE (38.4% vs 17.5%; P < 0.0001). A significant improvement in pain scores (>33% and >50% reductions) was also reported for BTP treated with FE. Pain scores for patients with BTP with a neuropathic component (13 patients) were lower with FE than for those receiving placebo, but the difference was not significant. AEs were of mild or moderate severity and typical of opioid drugs.

CONCLUSIONS

This newly developed galenic formulation with a higher early systemic exposure and a shorter Tmax compared with oral transmucosal fentanyl citrate makes FE a particularly suitable formulation for the management of BTP in opioid-treated cancer patients due to the very rapid onset of action. FE provided significant improvement in pain intensity of BTP compared with placebo as early as 6 minutes' postadministration with a sustained effect over 60 minutes. FE was well tolerated by patients. ClinicalTrials.gov identifier: NCT 01842893.

[Cancer pain management]

Pain is a significant and alarming symptom of cancer seriously affecting the activity and quality of life of patients. Recent research proved that inadequate analgesia shortens life expectancy. Therefore, pain relief is not only a possibility but a professional, ethical and moral commitment to relieve patients from suffering, as well as ensure their adequate quality of life and human dignity. Proper pain relief can be achieved with medical therapy in most of the cases and the pharmacological alternatives are available in Hungary. Yet medical activity regarding pain relief is far from the desired. This paper gives a short summary of the guidelines on medical pain management focusing particularly on the use of opioids.

Clinical pharmacology of fentanyl buccal tablet for the treatment of breakthrough pain

Fentanyl buccal tablet (FBT) is a new formulation of fentanyl providing rapid-onset analgesia for the treatment of breakthrough pain. FBT has been approved for the management of breakthrough pain in patients with cancer who are already receiving and who are tolerant to opioid therapy for underlying persistent pain. FBT has demonstrated a favorable pharmacokinetic profile, which is closely aligned to the rapid onset and duration of an episode of breakthrough pain, and is generally safe and well tolerated.

Prevalence of breakthrough cancer pain: a systematic review and a pooled analysis of published literature

CONTEXT

Despite the large body of literature on breakthrough cancer pain (BTcP), an accurate estimate of BTcP prevalence is still not available.

OBJECTIVES

To provide an estimate of BTcP prevalence and investigate the association between different prevalence rates and possible determinants.

METHODS

We conducted MEDLINE and EMBASE searches for studies published from 1990 to 2012 reporting data on BTcP prevalence in adult cancer populations. Pooled prevalence rates from observational studies with an acceptable methodological quality were computed. The association between BTcP prevalence and possible predictors was investigated using subgroup analyses and meta-regression.

RESULTS

Twenty-seven observational studies were identified. When quality criteria were applied, only 19 studies were included in the pooled analysis. The overall pooled prevalence was 59.2%, with high heterogeneity. The lowest prevalence rates were detected in studies conducted in outpatient clinics (39.9%), and the highest prevalence was reported in studies conducted in hospice (80.5%). The association between BTcP prevalence and other determinants such as publication year, age, gender, metastatic disease prevalence, or baseline pain intensity did not reach statistical significance.

CONCLUSION

In the context of a large between-studies heterogeneity, more than one in two patients with cancer pain also experiences BTcP, with some variability according to clinical and organizational variables.

Breakthrough cancer pain: an observational study of 1000 European oncology patients

CONTEXT

Breakthrough pain is common in patients with cancer and is a significant cause of morbidity in this group of patients.

OBJECTIVES

The aim of this study was to characterize breakthrough pain in a diverse population of cancer patients.

METHODS

The study involved 1000 cancer patients from 13 European countries. Patients were screened for breakthrough pain using a recommended diagnostic algorithm and then questioned about the characteristics and management of their pain.

RESULTS

Of the 1000 patients, 44% reported incident pain, 41.5% spontaneous pain, and 14.5% a combination. The median number of episodes was three a day. The median time to peak intensity was 10 minutes, with the median for patients with incident pain being five minutes (P < 0.001). The median duration of untreated episodes was 60 minutes, with the median for patients with incident pain being 45 minutes (P = 0.001). Eight hundred six patients stated that pain stopped them doing something, 66 that it sometimes stopped them doing something, and only 107 that it did not interfere with their activities. Patients with incident pain reported more interference with walking ability and normal work, whereas patients with spontaneous pain reported more interference with mood and sleep. As well, 65.5% of patients could identify an intervention that improved their pain (29.5%, pharmacological; 23%, nonpharmacological; 12%, combination). Regarding medications, 980 patients were receiving an opioid to treat their pain, although only 191 patients were receiving a transmucosal fentanyl product licensed for the treatment of breakthrough pain.

CONCLUSION

Breakthrough cancer pain is an extremely heterogeneous condition.

Opioids for the management of breakthrough pain in cancer patients

BACKGROUND

This review is an update of a previously published review in the Cochrane Database of Systematic Reviews (Issue 1, 2006). Breakthrough pain is a transient exacerbation of pain that occurs either spontaneously or in relation to a specific predictable or unpredictable trigger despite relative stable and adequately controlled background pain. Breakthrough pain usually related to background pain and is typically of rapid onset, severe in intensity and generally self limiting with a mean duration of 30 minutes. Breakthrough pain has traditionally been managed by the administration of supplemental oral analgesia (rescue medication) at a dose proportional to the total around-the-clock (ATC) opioid dose.

OBJECTIVES

To determine the efficacy of opioid analgesics given by any route, used for the management of breakthrough pain in patients with cancer, and to identify and quantify, if data permitted, any adverse effects of this treatment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and trial registries in January 2005 for the original review, and again on 6 February 2013 for this update.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of opioids used as rescue medication against active or placebo comparator in patients with cancer pain. Outcome measures sought were reduction in pain intensity measured by an appropriate scale, adverse effects, attrition, patient satisfaction and quality of life. We applied no language restrictions.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected and examined eligible studies. We retrieved full text if any uncertainty about eligibility remained. We screened non-English texts. We conducted quality assessment and data extraction using standardised data forms. We compared drug and placebo dose, titration, route and formulation and recorded details of all outcome measures (if available).

MAIN RESULTS

The original review included four studies (393 participants), all concerned with the use of oral transmucosal fentanyl citrate (OTFC) in the management of breakthrough pain. Two studies examined the titration of OTFC, one study compared OTFC versus normal-release morphine and one study compared OTFC versus placebo.Fifteen studies (1699 participants) met the inclusion criteria for this update. All studies reported on the utility of seven different transmucosal fentanyl formulations, five of which were administered orally and two nasally. Eight studies compared the transmucosal fentanyl formulations versus placebo, four studies compared them with another opioid, one study was a comparison of different doses of the same formulation and two were randomised titration studies. Oral and nasal transmucosal fentanyl formulations were an effective treatment for breakthrough pain. When compared with placebo or oral morphine, participants gave lower pain intensity and higher pain relief scores for transmucosal fentanyl formulations at all time points. Global assessment scores also favoured transmucosal fentanyl preparations. One study compared intravenous with the transmucosal route and both were effective.

AUTHORS' CONCLUSIONS

Oral and nasal transmucosal fentanyl is an effective treatment in the management of breakthrough pain. The RCT literature for the management of breakthrough pain is relatively small. Given the importance of this subject, more trials, including head-to-head comparisons of the available transmucosal fentanyl formulations are required.

Relationship between background cancer pain, breakthrough pain, and analgesic treatment: a preliminary study for a better interpretation of epidemiological and clinical studies

BACKGROUND

The different operational definitions of breakthrough cancer pain (BTcP) has generated unclear epidemiological data.

METHODS

A consecutive sample of patients was categorized on the basis of their background pain intensity, background analgesic treatment, and the presence of BTcP.

RESULTS

A total of 265 patients were surveyed; 117 patients had background pain and 91 patients presented peaks of pain intensity distinguishable from background pain. Of 117 patients with background pain, 49 patients were re-assessed after optimization of background analgesia (T1) within a mean of 8.2 days. Pain intensity significantly decreased in comparison with values recorded at admission (p < 0.0005); 75.5% of these patients had BTcP episodes, with a significant decrease in the number BTcP episodes in comparison with T0 (p < 0.0005). The mean BTcP intensity was significantly lower in comparison with T0 (p < 0.0005). Finally, the mean duration of untreated BTcP episodes decreased significantly in comparison with T0 (p = 0.016). After optimization of analgesic therapy, most patients with moderate or severe background pain receiving opioids for moderate pain, patients with moderate or severe pain receiving strong opioids, and patients with moderate or severe pain receiving no opioids moved to the group of patients with mild pain receiving strong opioids. The difference was significant (p = 0.022).

CONCLUSION

Patients having good pain control after optimization of the analgesic regimen may have a decrease in number, intensity, and duration of BTcP, although the general prevalence of BTcP remains unchanged.

Fentanyl for the treatment of tumor-related breakthrough pain

BACKGROUND

Breakthrough cancer pain (BTCP) is common among cancer patients and markedly lowers their quality of life. The treatment for BTCP episodes that is recommended in current guidelines involves extended-release formulations in combination with rapid-onset and short-acting opioids. In the past few years, several new preparations of fentanyl, an opioid with a very rapid onset, have been approved for this indication. Treating physicians need to be aware of the clinical differences between the newer fentanyl preparations and immediate-release opioids.

METHODS

We searched the PubMed and Embase databases for randomized controlled trials (RCTs) of fentanyl for buccal, sublingual or intranasal administration in comparison with other opioids or a different fentanyl preparation for the treatment of BTCP.

RESULTS

In 6 trials of buccal, sublingual or intranasal fentanyl versus oral immediate-release opioids for the treatment of BTCP episodes, the use of fentanyl was associated with significantly less intense pain. In particular, fentanyl more often lowered the intensity of pain by at least 33% (range between studies: 13% to 57%) or by at least 50% (range between studies: 9% to 38%) within 15 minutes. Please change to "versus" if you agree.] Dose titration should begin at the lowest dose. When one fentanyl preparation is exchanged for another, the effective dose will probably differ.

CONCLUSION

The newer fentanyl preparations extend the treatment options for BTCP. They relieve pain within a short time better than conventional, immediate-release oral opioids do and may therefore be very helpful for patients with suddenly arising, intense, and short-lasting BTCP episodes. Further comparative trials are urgently needed.

Fentanyl sublingual spray for breakthrough pain in cancer patients

Breakthrough pain is a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain. Typically, breakthrough pain has a fast onset and short duration, and a significant impact on patients’ quality of life. Normal-release oral opioids are the traditional pharmacological approach for patients who are receiving an around the clock opioid regimen; however, their onset and duration of action may not be suitable for treating many breakthrough pains. Efforts to provide nonparenteral opioid formulations that could provide more rapid, and more effective, relief of breakthrough pain have led to the development of transmucosal opioid formulations including fentanyl sublingual spray (FSLS). This is a formulation of fentanyl available in doses of 100, 200, 400, 600, and 800 μg strengths approved for the management of breakthrough pain in adult cancer patients already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. Published pharmacokinetic, efficacy, tolerability, and safety data suggest that FSLS has a valuable role to play in the symptomatic pharmacological management of breakthrough pain. The effective dose of FSLS is determined by titration according to the needs of the individual patient.

Effect of the Botanical Compound LCS101 on Chemotherapy-Induced Symptoms in Patients with Breast Cancer: A Case Series Report

The treatment of breast cancer invariably results in severe and often debilitating symptoms that can cause significant distress and severely impair daily function and quality-of-life (QOL). We treated a series of 20 female breast cancer patients with the botanical compound LCS101 as adjuvant to conventional chemotherapy. At the end of the treatment regimen, patients rated their symptoms. 70% reported that they had either no or mildly severe levels of fatigue; 60% none to mildly severe weakness; 85% none to mildly severe pain; 70% none to mildly severe nausea; and 80% none to mildly severe vomiting. Only 20% reported severe impairment of overall function, and only 40% severely impaired QOL. No toxic effects were attributed by patients to the LCS101 treatment, and 85% reported that they believed the botanical compound had helped reduce symptoms. The effects of LCS101 on clinical outcomes in breast cancer should be tested further using randomized controlled trials.

How nurses assess breakthrough cancer pain, and the impact of this pain on patients' daily lives--results of a European survey

PURPOSE

To increase our knowledge of how nurses assess breakthrough cancer pain (BTCP); and whether they find it difficult to distinguish BTCP from background pain; how they estimate the impact of BTCP on patients' daily lives, and the factors that nurses consider to induce BTCP. Variations in their use of assessment tools and their ability to distinguish between different types of pain were also examined in terms of the number of years of oncology nursing experience and the practice in different countries.

METHODS

In total, 1241 nurses (90% female) who care for patients with cancer, from 12 European countries, completed a survey questionnaire.

KEY RESULTS

Half the sample had >9 years of experience in oncology nursing. Although 39% had no pain assessment tool to help them distinguish between types of pain, 95% of those who used a tool found it useful. Furthermore, 37% reported that they had problems distinguishing background pain from BTCP. Movement was identified as the factor that most commonly exacerbated BTCP across all countries. The nurses reported that BTCP greatly interfered with patients' everyday activities, and they rated the patients' enjoyment of life as most strongly affected. The use of tools and the ability to distinguish between different pains varied between European countries and with years of experience in oncology nursing.

CONCLUSIONS

The nurses reported that BTCP greatly interfered with patients' lives, and many nurses had problems distinguishing between background pain and BTCP. Nurses require more knowledge about BTCP management, and guidelines should be developed for clinical use.

The management of pain in metastatic bone disease

BACKGROUND

Metastatic bone disease is a common cause of pain in cancer patients. A multidisciplinary approach to treatment is often necessary because simplified analgesic regimens may fail in the face of complex pain generators, especially those involved in the genesis of neuropathic pain. From the origins of formalized guidelines by the World Health Organization (WHO) to recent developments in implantable therapies, great strides have been made to meet the needs of these patients.

METHODS

The authors review the existing literature on the pathophysiology and treatment options for pain generated by metastatic bone disease and summarize classic and new approaches.

RESULTS

Relatively recent animal models of malignant bone disease have allowed a better understanding of the intimate mechanisms involved in the genesis of pain, resulting in a mechanistic approach to its treatment. Analgesic strategies can be developed with specific targets in mind to complement the classic, opioid-centered WHO analgesic ladder obtaining improved outcomes and quality of life. Unfortunately, high-quality evidence is difficult to produce in pain medicine, and these concepts are evolving slowly.

CONCLUSIONS

Treatment options are expanding for the challenging clinical problem of painful metastatic bone disease. Efforts are concentrated on developing alternative nonopioid approaches that appear to increase the success rate and improve patients' quality of life.

Achievement of personalized pain goal in cancer patients referred to a supportive care clinic at a comprehensive cancer center

BACKGROUND

Cancer pain initiatives recommend using the personalized pain goal to tailor pain management. This study was conducted to examine the feasibility and stability of personalized pain goal, and how it compares to the clinical pain response criteria.

METHODS

Records of 465 consecutive cancer patients seen in consultation at the Supportive Care Clinic were reviewed. Pain relief was assessed as clinical response (≥30% or ≥2 point pain reduction) and personalized pain goal response (pain ≤ personalized pain goal).

RESULTS

One hundred fifty-two (34%), 95 (21%), and 163 (37%) patients presented with mild (1-4), moderate (5-6), and severe (7-10) pain, respectively. Median age (59 years), males (52%), and advanced cancer status (84%) did not differ by pain category. Median personalized pain goal at initial clinic consult was 3 (interquartile range, 2-3), was similar across pain groups, and remained unchanged (P = .57) at follow-up (median, 14 days). Clinical response was higher among patients with severe pain (60%) as compared with moderate (40%) and mild pain (33%, P < .001). Personalized pain goal response was higher among patients with mild pain (63%) as compared with moderate (44%) and severe pain (27%, P < .001). By using personalized pain goal response as the gold standard for pain relief, the sensitivity of clinical response was highest (98%) among patients with severe pain, but it had low specificity (54%). In patients with mild pain, clinical response was most specific for pain relief (98%), but had low sensitivity (52%).

CONCLUSIONS

Personalized pain goal is a simple patient-reported outcome for pain goals. The majority of patients were capable of stating their desired level for pain relief. The median personalized pain goal was 3, and it was highly stable at follow-up assessment.

Episodic (breakthrough) pain prevalence in a population of cancer pain patients. Comparison of clinical diagnoses with the QUDEI--Italian questionnaire for intense episodic pain

CONTEXT

Breakthrough/episodic pain (BP-EP) diagnosis is often based on clinical experience, and different opinions exist, even among palliative care clinicians, about its definition and application to clinical practice.

OBJECTIVES

The primary aim of this study was to assess the prevalence and clinical characteristics of BP-EP in an unselected Italian population of patients with cancer-related chronic pain, based on clinical diagnosis and on the use of an assessment tool, the Questionnaire for Intense Episodic Pain (QUDEI).

METHODS

A cross-sectional multicenter prevalence study of 240 consecutive cancer pain patients was carried out. The physicians participating in the study attended a training session aimed at defining and recognizing BP-EP. The QUDEI, a screening and assessment tool based on patient interview, diagnosed the presence of BP-EP in patients regularly taking analgesics for the previous three days and who had at least one pain flare in the previous 24 hours. Clinical evaluation and questionnaire application were carried out by different health care providers.

RESULTS

The estimated prevalence of BP-EP was 73% (95% confidence interval [CI] = 67%, 79%) when the diagnosis was made by physicians and 66% (95% CI = 60%, 72%) when the QUDEI was applied (86% agreement). When only patients with baseline pain less than or equal to six were included in the analysis, the above prevalences decreased to 67% and 60%, respectively.

CONCLUSION

Because BP-EP is a significant phenomenon in cancer pain management, its appropriate recognition requires a more widely, internationally accepted general definition and specific validated tools for its screening and evaluation.

Pharmacokinetics of fentanyl buccal tablet: a pooled analysis and review

Fentanyl buccal tablet (FBT) is indicated for the treatment of breakthrough pain in patients who are already receiving and are tolerant to opioid therapy for underlying, persistent cancer pain. FBT is designed to enhance the rate and efficiency of absorption of fentanyl through the buccal mucosa. FBT was shown to be dose proportional from 100 to 1,300 μg. This analysis provides an overview of the pharmacokinetic profile of FBT based on pooled data from nine pharmacokinetic studies. In all, 365 healthy non-opioid-tolerant adults receiving naltrexone were included in the analysis. Single-dose (100 to 1,300 μg) pharmacokinetic parameters were dose normalized to 100 μg. Pharmacokinetic measures included maximum observed plasma drug concentration (C(max)), plasma drug concentration versus time curve from time zero to infinity (AUC(0-∞)), time to reach C(max) (T(max)), apparent plasma terminal elimination rate constant, and elimination half-life. After FBT administration, fentanyl was rapidly absorbed, with T(max) ranging from 20 minutes to 4 hours postdose. Mean AUC(0-∞) was 1.49 ng•hour/mL, and mean C(max) was 0.237 ng/mL. However, plasma fentanyl concentration reached 80% of C(max) within 25 minutes and was maintained through 2 hours after administration. Based on the individual studies, bioequivalence was shown for sublingual and buccal tablet placement, and no significant effect of dwell time (duration of FBT presence in the oral cavity) was observed. The pharmacokinetic profile of FBT was characterized by rapid absorption, which is consistent with the rapid-onset efficacy profile of FBT observed in clinical studies.

Transformation of acute cancer pain to chronic cancer pain syndromes

For many cancer survivors, disease-related long-term morbidities and the application of advanced cancer treatments have resulted in the development of a chronic pain state. This brief review explores the relationship between what is known about the treatment of active cancer pain syndromes-both continuous pain and breakthrough pain-and persisting pain syndromes in cancer survivors. We also posit that because there is evidence to suggest that poorly treated acute pain can lead to protracted pain conditions, acute pain should be recognized and treated promptly, both for short- and long-term gain. In the short term, better acute pain treatment can improve functionality and psychological well-being, whereas in the long term, mounting evidence suggests that it could prevent of future chronic pain.

Breakthrough pain in malignant and non-malignant diseases: a review of prevalence, characteristics and mechanisms

Breakthrough pain or transient worsening of pain in patients with an ongoing steady pain is a well known feature in cancer pain patients, but it is also seen in non-malignant pain conditions with involvement of nerves, muscles, bones or viscera. Continuous and intermittent pain seems to be a general feature of these different pain conditions, and this raises the possibility of one or several common mechanisms underlying breakthrough pain in malignant and non-malignant disorders. Although the mechanisms of spontaneous ongoing pain and intermittent flares of pain (BTP) may be difficult to separate, we suggest that peripheral and/or central sensitization (hyperexcitability) may play a major role in many causes of BTP. Mechanical stimuli (e.g. micro-fractures) changes in chemical environments and release of tumour growth factors may initiate sensitization both peripherally and centrally. It is suggested that sensitization could be the common denominator of BTP in malignant and non-malignant pain.

Long-term course of pain in breast cancer survivors: a 4-year longitudinal study

After successful treatment of early breast cancer, many women still report pain symptoms, and attribute them to the previous illness or its treatment. However, knowledge about the long-term course of pain in breast cancer is limited. Baseline assessment included 3,088 women who received a breast cancer diagnosis on average 2 years prior to enrollment, and who completed typical medical treatments. After 4 years, a subsample of 2,160 recurrence-free women (70%) was re-assessed. The major outcome variable was the composite index for general pain symptoms. Over the 4-year course, a slight but significant increase in pain was reported. If only medical variables were examined, a triple interaction between surgery type, breast cancer stage, and time indicated that pain scores increased in most subgroups, while they decreased in stage II women after mastectomy and stage III women after lumpectomy. Using a regression analytical approach, psychological and other variables added significantly to the prediction of pain persistence. Regression analysis revealed that pain symptoms increased in those women taking tamoxifen at baseline, in those reporting depression at baseline or stressful life events during the first 12 months after enrollment. Exercise at baseline had a beneficial effect on pain recovery. The persistence or increase of pain symptoms in women surviving breast cancer is associated with some medical factors (surgery type, tamoxifen use), but also with psychological factors. Pain should be a standard outcome variable in the evaluation of cancer treatment programs.

A pilot study to identify correlates of intentional versus unintentional nonadherence to analgesic treatment for cancer pain

Existing studies of medication adherence treat "nonadherence" as a monolithic concept. The goal of this study was to isolate correlates of intentional versus unintentional nonadherence for analgesic treatment for cancer pain. Patients were recruited from outpatient oncology clinics in the middle Atlantic region, ≥18 years old, and diagnosed with solid tumors, and had an active prescription of at least one around-the-clock analgesic. The Morisky Medication Adherence Scale (MMAS) was used to assesses "unintentional" (forgetfulness/carelessness) and "intentional" (stopping use of medication if feeling better or worse) dimensions of analgesic nonadherence. A visual analog scale was used to assess the percentage of analgesic doses taken in the preceding month. A majority of participants (85.5%) took prescribed analgesics in the index period. However, 51% reported taking only up to 60% of the analgesic doses prescribed to them. Stopping taking analgesics when feeling better was the most commonly reported nonadherence behavior (74%); those reporting "intentional" nonadherence when feeling better were more likely to report not using analgesics in the index week (100% vs. 67.7%; p = .029) and agree that pain medication can keep you from knowing what is going on in your body (p = .029) and were less likely to need stronger pain medication (33.3% vs. 81.5%; p = .003). "Unintentional" nonadherence, i.e., forgetfulness/carelessness, though associated with many analgesic beliefs, was not associated with measures of analgesic use in the index period. These preliminary data indicate that different heuristics underlie intentional versus unintentional nonadherence to analgesia and that intentional and unintentional nonadherence behaviors may have different implications for pain treatment outcomes.